Clinical Review & Education

Review

Scalp Reconstruction
An Algorithmic Approach and Systematic Review
Shaun C. Desai, MD; Jordan P. Sand, MD; Jeffrey D. Sharon, MD; Gregory Branham, MD; Brian Nussenbaum, MD

Journal Club Slides at

IMPORTANCE Reconstruction of the scalp after acquired defects remains a common challenge jamafacialplasticsurgery.com
for the reconstructive surgeon, especially in a patient with a history of radiation to the area. CME Quiz at
jamanetworkcme.com and
OBJECTIVE To review the current literature and describe a novel algorithm to help guide the CME Questions page 72
reconstructive surgeon in determining the optimal reconstruction from a cosmetic and
functional standpoint. Pertinent surgical anatomy, considerations for patient and technique
selection, reconstructive goals, as well as the reconstructive ladder, are also discussed.

EVIDENCE REVIEW A PubMed and Medline search was performed of the entire English
literature with respect to scalp reconstruction. Priority of review was given to those studies
with higher-quality levels of evidence.

FINDINGS Size, location, radiation history, and potential for hairline distortion are important
factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play
a major role in the potential for primary or local flap closure. Patients with medium to large
defects and a history of radiation will likely benefit from free tissue transfer.

CONCLUSIONS AND RELEVANCE Ideal reconstruction of scalp defects relies on a

comprehensive understanding of scalp anatomy, a full consideration of the armamentarium
Author Affiliations: Department of
of surgical techniques, and a detailed appraisal of patient factors and expectations. The Otolaryngology–Head and Neck
simplest reconstruction should be used whenever possible to provide the most functional Surgery, Washington University
and aesthetic scalp reconstruction, with the least amount of complexity. School of Medicine, St Louis,
Missouri.
Corresponding Author: Brian
LEVEL OF EVIDENCE NA. Nussenbaum, MD, Department of
Otolaryngology–Head and Neck
Surgery, Washington University
JAMA Facial Plast Surg. 2015;17(1):56-66. doi:10.1001/jamafacial.2014.889
School of Medicine, 660 S Euclid Ave,
Published online November 6, 2014.
Campus Box 8115, St Louis, MO 63110
(nussenbaumb@ent.wustl.edu).

T
he scalp covers the calvarium and is therefore critical not
only for normal cosmesis but also for protecting the
intracranial structures. It requires reconstruction when
damaged by various causes, including benign or malignant tumor
excision, infection, trauma, radiation necrosis, thermal or electri-
cal burns, congenital lesions, or renovation of a cosmetically
unappealing scar or alopecia. Modern surgical techniques have
allowed the reconstructive surgeon to repair most scalp defects
with success and prevent potentially disastrous complications
from exposed bone, such as calvarial desiccation, sequestration,
and sepsis.1 Use of the reconstructive ladder is highly pertinent to
the repair of scalp defects. On each successive step of the ladder,
the surgeon balances the complexity of the reconstruction
against its necessity. In other words, the simplest reconstruction
should be used whenever possible to provide the most functional
and aesthetic scalp reconstruction, with the least amount of
complexity.
Scalp Anatomy
Scalp Layers
As with surgery in any location, a detailed understanding of the
anatomy is key to planning a successful reconstruction. The layers
of the scalp are frequently described by the mnemonic “SCALP.” This
stands for Skin, subCutaneous tissue, galea Aponeurotica, Loose
areolar tissue, and Pericranium (Figure 1). The scalp contains the
thickest integument on the body, ranging from 3 to 8 mm in depth.2,3
When considering reconstruction, the unique characteristics of scalp
skin and its hair-bearing nature must be considered, to provide an
aesthetically pleasing reconstruction.4 The scalp’s blood vessels, lym-
phatic system, and nerves run superficial to the galea aponeurotica
in the subcutaneous tissues. This is an important consideration when
planning local flaps, since raising a flap superficial to the galea can
impair flap vascularity.

56 JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1 jamafacialplasticsurgery.com

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015

 Scalp Reconstruction Review Clinical Review & Education

Figure 1. Layers of the Scalp and Temporoparietal Region

Subcutaneous tissue Skin

Galea
Loose areolar tissue

Pericranium

Calvarium

Calvarium

Pericranium

Temporal muscle with deep

and middle temporal artery

Temporalis fascia
Temporoparietal fascia
with STA
Subcutaneous tissue

Skin
Superficial layer
temporalis fascia
Frontal branch
Deep layer
facial nerve
temporalis fascia
Superficial
temporal flat pad
Zygoma
Deep temporal
fat pad

Masseter
SMAS

Parotidomasseteric fascia
Mandible

Parotid gland

SMAS indicates superficial muscular aponeurotic system; STA, superficial temporal artery.

The galea aponeurotica provides strength to the overlying in-
tegument and blends with several other scalp structures. The galea
is continuous anteriorly with the frontalis muscle fascia, posteriorly
with the occipitalis muscle fascia, and laterally with the temporo-
parietal fascia. The galea itself is very inelastic and provides the rea-
son for the “tight” and “loose” portions of the scalp (Figure 2). From
the scalp vertex traveling caudally, the galea is fully formed, and the
skin is tight and inelastic. Conversely, where the galeal edges blend
into the temporoparietal fascia and scalp musculature fascia, the skin
has improved mobility and can be more easily rearranged. It is im-
portant to note that the galea also fuses with the pericranium at the
linea temporalis in the lateral frontal region.5 This is a key point for
reconstruction because many local flaps seek to mobilize scalp from
these looser locations and may require release of ligamentous at-
tachments or considerable undermining depending on the loca-
tion of the donor site tissue.1
Below the galea there is a loose connective tissue responsible
for much of the mobility of the overlying scalp skin. This layer is also
known as the subgaleal fascia, the innominate fascia, or the subapo-
neurotic plane.6,7 Scalp flaps are most frequently raised within this
layer because it is easily dissected, and the critical neurovascular
structures remain superficial and unharmed. The cranial perios-
teum is tightly adherent to the calvarium and is the deepest layer
of the scalp’s soft tissue. This layer is typically kept intact during scalp
reconstruction and can serve as a vascularized surface for skin graft-
ing depending on the reconstructive plan. Not infrequently, how-
ever, the scalp defect might include the absence of the pericra-
nium. The pericranium is critically important for maintaining blood
supply to the underlying calvarial bone.
The calvarium is composed of frontal, parietal, temporal, oc-
cipital, and sphenoid bones. These bones are generally composed
of 3 layers, including an outer table, a central diploic space, and an
inner table. The tables vary in thickness depending on the location
and age and genetic characteristics of the patient. Pediatric cal-
varium is typically very malleable and useful in terms of providing
source material for a number of reconstructive grafts.8 Alterna-
tively, skull bone of elderly individuals is hard, brittle, and less adapt-
able to manipulation.
The anatomy of the temporal region is more complex than the
rest of the scalp and deserves additional attention. Above the tem-
poral line, or the superior attachment of the temporalis muscle, the
scalp layers are as described herein. Just below the attachment of

jamafacialplasticsurgery.com JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1 57

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015

 Clinical Review & Education Review
Figure 2. Tight and Loose Layers of the Scalp
Tight scalp
Loose scalp
the temporalis muscle, the skin, subcutaneous fat, and galea re-
main the same. However, traveling inferiorly over the muscle, the
galeal layer transforms into the temporoparietal fascia. This fascia
is attached to the subcutaneous tissues and is continuous with the
frontalis muscle fascia anteriorly and the superficial muscular apo-
neurotic system inferiorly. This layer provides the mobility of the
looser areas of the scalp. The temporal branch of the facial nerve and
superficial temporal artery are located within the temporoparietal
fascia.9 Underneath the temporoparietal fascia exists a loose areo-
lar tissue separating it from the temporalis fascia of the temporalis
muscle. This temporalis fascia, however, splits into a deep layer and
superficial layer around the superficial temporal fat pad a few cen-
timeters superior to the zygomatic arch. Although originating as in-
dividual layers, the superficial layer of the deep temporal fascia, the
temporoparietal fascia, and the periosteum fuse to form a single
dense immobile layer at the level of the zygomatic arch. It is at this
point that the frontal branch of the facial nerve is most vulnerable
while it travels over the middle third of the zygomatic arch to inner-
vate the frontalis and corrugator muscles on their deep surface. Dis-
section in this area, such as during elevation of a hemicoronal or bi-
coronal scalp flap, is frequently performed in the plane deep to the
superficial layer of the deep temporal fascia to prevent facial nerve
injury.9
Vascularity and Lymphatics
The scalp is a highly vascular organ supplied by cutaneous arteries
arising from 4 separate systems from both the internal and exter-
nal carotid arteries (Figure 3).4,10 These vessels run in the subcuta-
neous plane superficial to the galea to form a vast system of collat-
eralization that can even allow for a single artery replantation of a
totally avulsed scalp.11,12 Anteriorly, the scalp is fed by the paired su-
praorbital and supratrochlear arteries originating from the ophthal-
mic artery from the internal carotid system. The lateral or tempo-
roparietal scalp is the largest and is supplied by the superficial
temporal artery, the terminal portion of the external carotid artery.
58 JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
Scalp Reconstruction
Once this artery reaches the superior helix of the ear, it branches to
form an anterior-frontal division and a posterior parietal division. Vas-
cular supply to the posterior portion of the scalp differs based on
the nuchal line. Superior to the nuchal line, the occipital arteries pro-
vide vascular supply. Inferior to this line, perforating musculocuta-
neous branches through the trapezius and splenius capitis muscles
are the main supply.1 The relatively small posterolateral area is sup-
plied by the posterior auricular artery, also arising from the external
carotid artery. An understanding of the main arterial supply of the
scalp is important when designing local flaps of the scalp because
axial blood supply must be incorporated.
Lymphatic drainage of the scalp is also located in the subcuta-
neous plane and typically follows the venous drainage. However, cu-
taneous malignant neoplasms of the scalp can have highly variable
patterns of spread, as shown with lymphoscintigraphy studies for
sentinel lymph node biopsies for scalp melanomas. These studies
show that lymphatic drainage can be found in the parotid, postau-
ricular, suboccipital, posterior cervical, and jugulodigastric lymph
nodes.13,14
Innervation
Innervation to the scalp is provided by the trigeminal nerve, the cer-
vical spinal nerves, and branches from the cervical plexus. The su-
praorbital and supratrochlear nerves supply the skin of the fore-
head, the anterior hairline region, and the frontoparietal scalp. The
zygomaticotemporal nerve provides sensation to the region lateral
to the brow up through the temporal line. The auriculotemporal
nerve provides much of the sensation to the lateral scalp. Posteri-
orly, sensation is transmitted through both the greater and lesser oc-
cipital nerves. These nerves are formed from the dorsal rami of the
cervical spinal nerves and the cervical plexus, respectively. The
greater occipital nerve typically emerges from the semispinalis
muscle about 3 cm below the occipital protuberance and 1.5 cm lat-
eral to the midline.15
Patient and Technique Selection
Reconstructive planning for a scalp defect must take into account
the extrinsic and intrinsic factors of the patient (Box). The surgeon
should assess the overall health of the patient and his or her social
situation, ability and commitment for wound care, and expecta-
tions for reconstructive surgery.16 Patient factors such as diabetes
mellitus, smoking, corticosteroid use, previous surgical incisions, and
prior or anticipated future scalp irradiation must be carefully evalu-
ated and included in the treatment planning. Prior scalp irradiation
produces skin fibrosis and can lead to intrinsic changes in the in-
tegument, creating a propensity for nonhealing wounds.17 This is a
critical point because local flaps or wound closures under tension,
which could survive in a nonirradiated scalp, may ultimately have di-
sastrous outcomes in patients with a radiation history. In a retro-
spective review18 of 73 scalp procedures, preoperative scalp radia-
tion, neoadjuvant or postoperative chemotherapy, and cerebrospinal
fluid leak were all noted to be statistically significant on univariate
analysis (P < .05) as risk factors for developing major complica-
tions. Potential need for postoperative radiation should also be con-
sidered when planning reconstruction, and greater consideration
should be given to free tissue transfer over local flaps.18,19
jamafacialplasticsurgery.com
 Scalp Reconstruction
4. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ.
The surgical anatomy of the scalp. Plast Reconstr Surg.
1991;87(4):603-612.
5. Moss CJ, Mendelson BC, Taylor GI. Surgical
anatomy of the ligamentous attachments in the
temple and periorbital regions. Plast Reconstr Surg.
2000;105(4):1475-1490.
6. Elliott LF, Jurkiewicz MJ. Scalp and calvarium. In:
Jurkiewicz MJ, Krizek TJ, Mathes SJ, Ariyan S, eds.
Plastic Surgery: Principles and Practice. St Louis, MO:
Mosby; 1990:419-440.
7. Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE.
Clinical applications of the subgaleal fascia. Plast
Reconstr Surg. 1991;87(4):615-626.
8. Ducic Y. Reconstruction of the scalp. Facial Plast
Surg Clin North Am. 2009;17(2):177-187.
9. Hoffmann JF. Reconstruction of the scalp. In:
Baker SR, ed. Local Flaps in Facial Reconstruction.
St Louis, MO: Mosby; 2007:638.
10. Seery GE. Surgical anatomy of the scalp.
Dermatol Surg. 2002;28(7):581-587.
11. Miller GDH, Anstee EJ, Snell JA. Successful
replantation of an avulsed scalp by microvascular
anastomoses. Plast Reconstr Surg. 1976;58(2):133-
136.
12. Kaplan HY, Yaffe B, Borenstein A. Single artery
replantation of totally avulsed scalp. Injury. 1993;24
(7):488-490.
13. Cappello ZJ, Augenstein AC, Potts KL,
McMasters KM, Bumpous JM. Sentinel lymph node
status is the most important prognostic factor in
patients with melanoma of the scalp. Laryngoscope.
2013;123(6):1411-1415.
14. Close LG, Goepfert H, Ballantyne AJ, Jesse RH.
Malignant melanoma of the scalp. Laryngoscope.
1979;89(8):1189-1196.
15. Mosser SW, Guyuron B, Janis JE, Rohrich RJ.
The anatomy of the greater occipital nerve:
implications for the etiology of migraine headaches.
Plast Reconstr Surg. 2004;113(2):693-697.
16. Becker GD, Adams LA, Levin BC. Secondary
intention healing of exposed scalp and forehead
bone after Mohs surgery. Otolaryngol Head Neck Surg.
1999;121(6):751-754.
17. Goessler UR, Bugert P, Kassner S, et al. In vitro
analysis of radiation-induced dermal wounds.
Otolaryngol Head Neck Surg. 2010;142(6):845-850.
18. Newman MI, Hanasono MM, Disa JJ, Cordeiro
PG, Mehrara BJ. Scalp reconstruction: a 15-year
experience. Ann Plast Surg. 2004;52(5):501-506.
19. Hussussian CJ, Reece GP. Microsurgical scalp
reconstruction in the patient with cancer. Plast
Reconstr Surg. 2002;109(6):1828-1834.
20. Sittitavornwong S, Morlandt AB.
Reconstruction of the scalp, calvarium, and frontal
sinus. Oral Maxillofac Surg Clin North Am. 2013;25
(2):105-129.
21. Chang KP, Lai CH, Chang CH, Lin CL, Lai CS, Lin
SD. Free flap options for reconstruction of
complicated scalp and calvarial defects: report of a
series of cases and literature review. Microsurgery.
2010;30(1):13-18.
22. Barrera A. The use of micrografts and
minigrafts for the treatment of burn alopecia. Plast
Reconstr Surg. 1999;103(2):581-584.
jamafacialplasticsurgery.com
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
23. Nordström REA. Punch hair grafting under
split-skin grafts on scalps. Plast Reconstr Surg. 1979;
64(1):9-12.
24. Limmer BL, Buchwach KA. Hair transplantation
using follicular unit micrografting. Facial Plast Surg.
1999;7(4):523-535.
25. Snow SN, Stiff MA, Bullen R, Mohs FE, Chao
WH. Second-intention healing of exposed
facial-scalp bone after Mohs surgery for skin cancer:
review of ninety-one cases. J Am Acad Dermatol.
1994;31(3, pt 1):450-454.
26. Subotic U, Kluwe W, Oesch V.
Community-associated methicillin-resistant
Staphylococcus aureus-infected chronic scalp
wound with exposed dura in a 10-year-old boy:
vacuum-assisted closure is a feasible option: case
report. Neurosurgery. 2011;68(5):1481-1483.
27. Powers AK, Neal MT, Argenta LC, Wilson JA,
DeFranzo AJ, Tatter SB. Vacuum-assisted closure
for complex cranial wounds involving the loss of
dura mater. J Neurosurg. 2013;118(2):302-308.
28. Marathe US, Sniezek JC. Use of the
vacuum-assisted closure device in enhancing
closure of a massive skull defect. Laryngoscope.
2004;114(6):961-964.
29. Brenner M. Scalp reconstruction. In: Branham
G, ed. Facial Soft Tissue Reconstruction. Shelton, CT:
Peoples Medical Publishing House; 2011:120.
30. Fang RC, Galiano RD. A review of becaplermin
gel in the treatment of diabetic neuropathic foot
ulcers. Biologics. 2008;2(1):1-12.
31. Harrison-Balestra C, Eaglstein WH, Falabela AF,
Kirsner RS. Recombinant human platelet-derived
growth factor for refractory nondiabetic ulcers:
a retrospective series. Dermatol Surg. 2002;28(8):
755-759.
32. Hershcovitch MD, Hom DB. Update in wound
healing in facial plastic surgery. Arch Facial Plast Surg.
2012;14(6):387-393.
33. Raposio E, Nordström RE, Santi PL.
Undermining of the scalp: quantitative effects. Plast
Reconstr Surg. 1998;101(5):1218-1222.
34. Ibhler N, Ziegler MC, Penna V, Eisdenhardt SU,
Stark GB, Bannasch H. An algorithm for oncologic
scalp reconstruction. Plast Reconstr Surg. 2010;126
(2):450-459.
35. Cox AJ III, Wang TD, Cook TA. Closure of a scalp
defect. Arch Facial Plast Surg. 1999;1(3):212-215.
36. Worlicek C, Kaufmann R. Divided full-thickness
skin graft for closure of circular and oval scalp
defects. J Dtsch Dermatol Ges. 2012;10(4):274-276.
37. Kuwahara M, Hatoko M, Tanaka A, Yurugi S,
Mashiba K. Simultaneous use of a tissue expander
and skin graft in scalp reconstruction. Ann Plast Surg.
2000;45(2):220.
38. Terranova W. The use of periosteal flaps in
scalp and forehead reconstruction. Ann Plast Surg.
1990;25(6):450-456.
39. Molnar JA, DeFranzo AJ, Marks MW.
Single-stage approach to skin grafting the exposed
skull. Plast Reconstr Surg. 2000;105(1):174-177.
40. Mehrara BJ, Disa JJ, Pusic A. Scalp
reconstruction. J Surg Oncol. 2006;94(6):504-508.
41. Yeong EK, Huang HF, Chen YB, Chen MT. The
use of artificial dermis for reconstruction of full
thickness scalp burn involving the calvaria. Burns.
2006;32(3):375-379.
JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1
Review Clinical Review & Education
42. Tufaro AP, Buck DW II, Fischer AC. The use of
artificial dermis in the reconstruction of oncologic
surgical defects. Plast Reconstr Surg. 2007;120(3):
638-646.
43. Komorowska-Timek E, Gabriel A, Bennett DC,
et al. Artificial dermis as an alternative for coverage
of complex scalp defects following excision of
malignant tumors. Plast Reconstr Surg. 2005;115(4):
1010-1017.
44. Koenen W, Goerdt S, Faulhaber J. Removal of
the outer table of the skull for reconstruction of
full-thickness scalp defects with a dermal
regeneration template. Dermatol Surg. 2008;34(3):
357-363.
45. Gonyon DL Jr, Zenn MR. Simple approach to
the radiated scalp wound using INTEGRA skin
substitute. Ann Plast Surg. 2003;50(3):315-320.
46. Khan MA, Ali SN, Farid M, Pancholi M, Rayatt S,
Yap LH. Use of dermal regeneration template
(Integra) for reconstruction of full-thickness
complex oncologic scalp defects. J Craniofac Surg.
2010;21(3):905-909.
47. Jung SN, Chung JW, Yim YM, Kwon H.
One-stage skin grafting of the exposed skull with
acellular human dermis (AlloDerm). J Craniofac Surg.
2008;19(6):1660-1662.
48. Wilensky JS, Rosenthal AH, Bradford CR, Rees
RS. The use of a bovine collagen construct for
reconstruction of full-thickness scalp defects in the
elderly patient with cutaneous malignancy. Ann
Plast Surg. 2005;54(3):297-301.
49. Seyhan A, Yoleri L, Barutçu A. Immediate hair
transplantation into a newly closed wound to
conceal the final scar on the hair-bearing skin. Plast
Reconstr Surg. 2000;105(5):1866-1870.
50. Frodel JL, Mabrie D. Optimal elective scalp
incision design. Otolaryngol Head Neck Surg. 1999;
121(4):374-377.
51. Orticochea M. Four flap scalp reconstruction
technique. Br J Plast Surg. 1967;20(2):159-171.
52. Orticochea M. New three-flap reconstruction
technique. Br J Plast Surg. 1971;24(2):184-188.
53. Horch RE, Stark GB. The contralateral bilobed
trapezius myocutaneous flap for closure of large
defects of the dorsal neck permitting primary donor
site closure. Head Neck. 2000;22(5):513-519.
54. Uğurlu K, Ozçelik D, Hüthüt I, Yildiz K, Kilinç L,
Baş L. Extended vertical trapezius myocutaneous
flap in head and neck reconstruction as a salvage
procedure. Plast Reconstr Surg. 2004;114(2):339-350.
55. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. The
lower trapezius musculocutaneous flap revisited:
versatile coverage for complicated wounds to the
posterior cervical and occipital regions based on the
deep branch of the transverse cervical artery. Plast
Reconstr Surg. 2002;109(2):444-450.
56. Tanaka Y, Miki K, Tajima S, Akamatsu J,
Tsukazaki Y, Inomoto T. Reconstruction of an
extensive scalp defect using the split latissimus
dorsi flap in combination with the serratus anterior
musculo-osseous flap. Br J Plast Surg. 1998;51(3):
250-254.
57. Har-El G, Bhaya M, Sundaram K. Latissimus
dorsi myocutaneous flap for secondary head and
neck reconstruction. Am J Otolaryngol. 1999;20(5):
287-293.
58. Kim JC, Hadlock T, Varvares MA, Cheney ML.
Hair-bearing temporoparietal fascial flap
65
 Clinical Review & Education Review
Box. Considerations for Patient and Technique Selection
Medical and functional status of the patient
Patient preferences
Radiation history or need for postoperative radiation
Defect thickness, size, and location
Prior surgical procedures and previous incision placement
Status of pericranium and calvarial defects
Type of malignant neoplasm
Exposed dura with or without cerebrospinal fluid leak
Hair status and patient’s hair expectations
Alloplastic materials or grafts used in cranioplasty
are frequently reconstructed with custom-fabricated alloplastic
cranioplasty prostheses with polyetheretherketone, hard-tissue
replacement materials like polymethylmethacrylate or kryptonite
bone cement, bone grafts, resorbable materials, or titanium
plates.20 Cranioplastic reconstructions require coverage with
well-vascularized tissue. Dural defects with possible cerebrospi-
nal fluid leakage are also important to consider because wound
healing may be compromised from fluid accumulation and pos-
sible infection.21 In patients with complicated wounds with mul-
tiple variables, such as calvarial deficiencies, dural defects, or
cerebrospinal fluid leaks, a well-vascularized free flap may be the
ideal choice to improve the reconstructive outcome.21
The hair-bearing scalp is a highly visible and unique tissue, which
lacks a donor site that can closely approximate its characteristics.
Great care should be applied to aesthetic reconstructive tech-
niques with preservation of the patient’s hairlines and the scalp tis-
sue’s normal hair-bearing characteristics. High-tension wound clo-
sure or liberal use of cautery may lead to follicular destruction and
alopecic scars. This is particularly true when cautery is monopolar
and is used above the level of the galea in the vicinity of hair
follicles.
Reconstructive Goals
The main goals in scalp reconstruction are 2-fold: functional and cos-
metic. Functional considerations include protection of the cal-
varium to prevent desiccation and infection by providing an ad-
equate blood supply via vascularized tissue.1 Such protection should
provide adequate coverage to implant hardware (eg, alloplastic im-
plants), and to limit donor site morbidity.
In addition to the usual tenets of plastic surgery, including
replacing “like with like,” cosmetic considerations unique to scalp
reconstruction include maintaining an appropriate hairline and
limiting alopecia and scar appearance with aesthetically placed
incisions and attention to hair growth patterns. The concept of
replacing “like with like” includes attention being paid to skin
color match and thickness. Hair transplantation has gained
increased popularity and is a useful adjunctive therapy or second
revision procedure to areas of alopecia created from the defect or
from the reconstruction itself. Alopecia created from incisional
scars, skin grafts, or wounds closed under excessive tension can
60 JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
Scalp Reconstruction
be closed with mini or micro hair grafts.9,22-24 Further discussion
on hair transplantation is beyond the scope of this article.
Reconstructive Ladder
Secondary Intention
Secondary intention can be an acceptable option for reconstruc-
tion in selected clinical scenarios as long as certain criteria are met.
Secondary intention works optimally when there is a pericranial layer
present, generally on a concave surface, and in patients with lighter
skin. Disadvantages include longer healing time, which can some-
times delay adjuvant therapy, tenuous coverage with contour mis-
match, alopecia, and prominent telangiectasias (Table). However,
one retrospective study16 of 205 consecutive patients with Moh
wounds of the scalp followed 38 patients with exposed bone (de-
fined as no periosteum or pericranial layer) who healed with no in-
tervention except local wound care. The mean area of the exposed
bone area was 1074 mm2, with all 38 patients healing their wounds
without any signs of infection or tissue breakdown. The mean time
to epithelialize if at least pericranium was present was 7 weeks,
whereas bare bone took 13 weeks to heal. The authors16 concluded
that secondary intention is a viable and safe option in selected pa-
tients even if the pericranial layer is not present. Other authors25 have
reported similar experiences.
Wound Vacuum-Assisted Closure
Wound vacuum-assisted closure (ie, “wound VAC”) was intro-
duced in the late 1990s as a potential wound care option for pa-
tients with nonhealing wounds, such as pressure ulcers. However,
several studies have reported its used in scalp reconstruction in both
the pediatric and adult populations in difficult wounds. Subotic et
al26 reported a difficult case of a pediatric patient who had a scalp
and calvarial defect with exposed dura that closed with a wound VAC
over several weeks. Other authors27,28 have used this method as a
temporizing measure for complex defects until further reconstruc-
tion can be performed. Vacuum-assisted closure is thought to pro-
mote tissue granulation and decrease wound volume by debriding
devitalized tissue, decreasing bacterial colonization, promoting blood
flow, and removing excess serous fluid that might inhibit wound
healing.26,28,29 Contraindications to its use in the head and neck in-
clude grossly contaminated wounds, malignant neoplasm in the
wound bed, necrosis, and osteomyelitis.29 In rare cases of large, ex-
tensive wounds in patients who are not good candidates for other
options, hyperbaric oxygen therapy might be beneficial, although
there are limited data on this topic.
Growth factor therapy with becaplermin gel (Regranex; Ortho-
McNeil Pharmaceutical) is also a potential option for patients with
complicated scalp wounds as an adjunct to healing by primary in-
tention. Becaplermin or recombinant human platelet-derived
growth factor (rhPDGF) is currently approved by the US Food and
Drug Administration for treatment of neuropathic diabetic ulcers.30
Off-label use of rhPDGF has been described in the successful treat-
ment of a chronic scalp wound.31 However, this product is contra-
indicated in patients with known neoplasms at the site of applica-
tion because there is an unknown increased risk of malignant
disease.32 Ultimately, this material should be used with caution in
patients with a known neoplasm.
jamafacialplasticsurgery.com
 Scalp Reconstruction
Table. The Reconstructive Ladder of the Scalp
Reconstructive Ladder Advantages
Secondary intention 1. Does not require procedure to reconstruct
Primary closure 1. Quick procedure
2. Limited alopecia with good contour and
color match
3. Technically more straightforward
4. Easy to monitor site for tumor recurrence
Skin grafting 1. Quick reliable healing
2. Technically less challenging
3. Easy to monitor site for tumor recurrence
Local flap 1. Limited alopecia with good contour and
advancement color match
rotational 2. Usually single-stage surgery
transposition
Regional flap 1. Large amount of vascularized tissue
without a microvascular anastomosis
Tissue expansion 1. Limited alopecia with good contour and
color match
Free tissue transfer 1. Large surface area of vascularized tissue,
especially in poor wound bed (eg, radiation
history)
Surgical Technique
Primary Closure
Primary wound closure is always the simplest and preferred recon-
struction option if possible, but in the scalp this is not often the
case.29 Primary closure can generally be achieved in defects smaller
than 3 cm if not on a tight region of the scalp; however, primary clo-
sure of larger defects has been described usually on the looser areas
of the scalp where there is underlying muscle (Figure 2).33,34 To sum-
marize, the ability to close a scalp defect primarily relies heavily on
the size and location of the defect and if it lies in the looser regions
of the scalp. A considerable amount of undermining is necessary for
a tension-free closure, although the convex surface of the scalp lim-
its the mobility gain from undermining. Galeal-releasing incisions can
be placed parallel to the incision spaced roughly 15 to 20 mm apart
to release the galea, which is often the limiting factor in closure. Ga-
leal-relaxing incisions should be made with caution in an effort not
to injure the vasculature, which lies just superficial to the galeal layer,
and they do place the patient at slightly higher risk for hematoma.35
A 2-layer closure should be achieved, with the galea receiving most
of the tension. Less tension on the skin closure will limit postopera-
tive iatrogenic alopecia.9
Skin Grafting
Split-thickness skin grafting has been used as a quick, easy, and re-
liable method for reconstructing medium to large scalp defects when
cosmesis is not a concern. Full-thickness grafts have been de-
scribed in scalp reconstruction, although they are much less com-
mon. Proposed advantages of full-thickness grafting include less do-
nor site care, which can often be closed primarily and, thus, results
jamafacialplasticsurgery.com
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
Review Clinical Review & Education
Disadvantages
1. Alopecia of defect
2. Contour deformity, hypopigmentation,
and tenuous covering
3. Need base of viable tissue present (eg,
pericranium)
4. Longer healing time and prolonged
wound car
1. Limited usually to defects <3 cm
2. May require very large undermining and
galeal scoring
3. Can distort hairline position
1. Alopecia of defect
2. Contour deformity, hypopigmentation,
and tenuous covering
3. Donor site morbidity
1. Requires long flap incisions and large
amount of undermining
2. Can distort hairline position
1. Limited reach of flap to just the occipital
and temporoparietal regions
2. Additional technical expertise needed
3. Alopecia of defect
4. Donor site morbidity
1. Requires multiple staged surgical
procedures
2. Risk of implant infection
3. Cooperative patient
1. Alopecia of defect
2. Need subspecialty training to perform
3. Donor site morbidity
in quicker healing time, which can be advantageous in the debili-
tated elderly population.36 Other indications include grafting the do-
nor site in large rotational-advancement flaps or in cases with tis-
sue expansion as a temporary measure to provide coverage for the
defect.37 An available nutrient blood supply via the pericranium is
the preferred recipient bed for grafting; however, often the recon-
structive surgeon is left with bare calvarium devoid of any pericra-
nium or periosteum. In this situation, 3 methods have been de-
scribed. First, a large pericranial flap, preferably bipedicled, can be
rotated into the defect, at which point a graft can be placed during
the same procedure.38 Although less commonly described, a “sub-
galeal fascia” flap, which consists mainly of the loose areolar tissue
plane that is pedicled off a major scalp vessel can also be rotated into
the wound and immediately grafted.1,7 A second option described
by some authors39 involves drilling down the outer cortex of the cal-
varium to expose the diplopic space, which in turn helps promote
granulation tissue and a healing bed for secondary skin grafting. How-
ever, some authors18,34 describe the results as suboptimal and
fraught with wound-healing complications and unacceptable risks
of potential intracranial complications. A third option involves a de-
layed or 2-stage approach of packing the initial wound to allow for
a healthy granulation bed followed by a second visit for skin graft-
ing. The latter method has anecdotal reports in the literature of hav-
ing improved results, but no direct comparison trials have been per-
formed to date.40 Finally, serial excision of the skin graft over time
with serial advancement flaps and primary closure can be per-
formed to help with cosmesis in selected clinical situations.
In certain situations, the surgeon may desire to decrease op-
erative time or avoid a skin graft donor site wound. In these cases,
the use of alternative materials, such as artificial dermal regenera-
tion template (Integra), has demonstrated promise for compli-
JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1 61
 Clinical Review & Education Review
Figure 4. Small Scalp Vertex Defect
A B
cated thermal, oncologic, or radiation wounds.41-46 A report has
shown that when Integra heals on the scalp it is supple, pliable, uni-
form in texture, and may be stable to radiation treatment although
lacking in aesthetic appeal.46 Other biological materials that have
been shown to promote adequate healing include acellular human
dermis (AlloDerm) and bovine collagen construct.47,48 These bio-
engineered skin substrates may provide an adequate substitute for
selected patients.
Local Flaps
There are numerous local flaps that can be used in scalp reconstruc-
tion, including advancement, rotation, and transposition flaps. Lo-
cal flaps provide “like with like” and therefore are the preferable
method for closure of scalp defects in nonradiated patients with de-
fects that cannot be primarily closed. Local flaps are safe and have
complication rates as low as 3.4%.18 Tenets for success include de-
signing large flaps with wide bases, minimizing the number of flaps,
and avoiding suture lines in critical areas.40 Unlike the face, the scalp
does not have resting skin tension lines (aside from the forehead and
occiput), and therefore flap incisions are designed to maintain the
hairline and incorporate as much vascularity as possible.29 Larger
flaps are preferable, with substantial undermining to distribute the
wound closure tension over a wide area. Incisions through the hair-
bearing scalp should be parallel to the direction of the hair follicles,
with judicious use of cautery at the cut edges of the scalp to reduce
alopecia at the scar line.49 Hemostatic clips, such as Raney clips, on
the incisional edges provide hemostasis, and therefore cautery can
be avoided, which in turn, minimizes follicular damage.50 How-
ever, once the Raney clips are removed, limited bipolar cautery
should be used after there is reactive vasodilation of the vessels.
Finally, relaxing incisions should be made judiciously, and standing
cutaneous deformities often should be temporarily tolerated be-
cause excision can decrease vascularity in the flap. Usually, they will
flatten with time, and if excision is necessary, can be done in the
office setting.
In general, advancement flaps have a limited role in scalp
reconstruction owing to the inelastic nature of the scalp and are
mainly used in the temporoparietal scalp for small defects. More
62 JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
Scalp Reconstruction
A, Small scalp vertex defect with
exposed calvarium. B, O → Z
Rotational flaps for small scalp vertex
defect in a bald patient.
commonly, advancement flaps are combined with rotational
flaps, which have a wider application in scalp reconstruction,
because the natural convexity of the scalp is well suited for curvi-
linear incisions.29 Careful attention must be paid to camouflage
the incisions, particularly with respect to the anterior hairline, as
well as to avoid displacement of mobile structures, such as the
brow. In general, rotational advancement incisions should be
roughly 4 to 6 times the length of the original defect to accom-
modate the lack of elasticity of the scalp. Multiple rotational flaps
and transposition flaps afford the ability to distribute the tension
over several incision lines, and are especially helpful with medium
to large defects. Two classically described flaps include the O-to-Z
or “pinwheel” flap for small to medium vertex defects as well as
the 3- or 4-flap Ortichoa technique for repair of medium to large
frontal and occipital defects (Figure 4).51,52
Regional Flaps
Regional flaps, aside from the temporoparietal fascia flap, have lim-
ited indications, especially in the era of free-tissue transfer. How-
ever, these flaps can sometimes “save the day” in patients with poor
wound healing and/or history of radiation who need large amounts
of vascularized tissue but who are not good candidates for free tis-
sue transfer.34 They can also be a good option in the palliative care
setting.34 The most commonly described regional flap for scalp re-
construction includes the lower island trapezius flap and the latis-
simus dorsi musculocutaneous flaps.53-57 These flaps generally can
only reach the vertex and the temporal region, and the heavy tis-
sue often has a gravitational pull parallel to the pedicle, limiting its
geometric freedom for the inset. This often results in ischemia at the
distal aspect of the flap.
The temporoparietal fascia flap , a versatile fasciocutaneous flap
based on the frontal, parietal or both branches of the superficial tem-
poral artery, is often helpful in scalp reconstruction.58,59 This flap is
unique in that it can be designed as a local pedicled flap or a micro-
surgical free flap. In addition, it can be designed as a fascial flap or a
composite flap containing underlying bone or overlying hair-
bearing scalp.9 This flap can be particularly useful in complicated
defects that involve the frontal or temporal hairline.
jamafacialplasticsurgery.com
 Scalp Reconstruction
Figure 5. Large Scalp Defect
A B
A, Large scalp defect in a patient with history of radiation and exposed
calvarium. B, Anterolateral thigh flap with anastomosis of the left superficial
temporal artery and vein. Note that the donor vessel was traced more
Tissue Expanders
Controlled tissue expansion has become a valuable tool for recon-
struction of medium to large defects of the scalp, especially in cases
in which local flaps cannot provide enough coverage and when the
hairline is distorted. Controlled tissue expansion works by the pro-
cess of biological and mechanical creep. Biological creep involves cel-
lular proliferation and expansion with slow, sustained stress ap-
plied to the tissue. This results in increased epidermal thickness,
transient dermal thinning, and increased blood flow to the pro-
posed flap.35 Transient alopecia can be observed, although this usu-
ally resolves over time. Mechanical creep involves the expansion of
tissue secondary to realignment of the collagen bundles in re-
sponse to acute tension.35
Tissue expanders can be placed before a resection preopera-
tively provided there is no significant delay in treatment, or second-
arily after resection once the wound has stabilized. Because tissue
expansion exerts a considerable amount of force on the tissues, some
surgeons prefer to place them once the wound has stabilized. The
size of the base of the implant should be 2.5 times the area of the
defect.60 Tissue expansion should be placed only in stable nonra-
diated wounds because there is a reportedly high complication rate
in patients with a history of previous radiation, infection, and/or al-
loplastic materials.19
Intraoperative tissue expansion has been described as well and
has had varying success in closing difficult wounds. “External tis-
sue expansion” refers to various devices that are placed externally
on the scalp over the incision that slowly stretch the edges of the
wounds over time. Some case series with promising results have been
reported in the literature.61,62 However, further clinical experience
is warranted before widespread use of these novel devices.
Free Tissue Transfer
Microvascular free flaps are the most commonly used reconstruc-
tion for medium to large scalp defects, especially in difficult cases
of prior radiation, exposed neurocranial structures, alloplastic ma-
terial, and chronic infection.63 Free tissue transfer brings a consid-
erable bulk of vascularized tissue that can nicely contour to the cal-
jamafacialplasticsurgery.com
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
Review Clinical Review & Education
C
proximally into the parotid gland to achieve a higher-caliber vessel for
anastomosis. C, Closure of scalp defect with Penrose drain in place.
Photographs courtesy of Bruce H. Haughey, MBChB.
varium and provides a healthy recipient site for skin grafts. They are
also the mainstay for reconstruction of total scalp defects, when the
scalp has been avulsed and cannot be replanted. The superficial tem-
poral artery and vein provide convenient and adequately sized re-
cipient vessels for anastomosis. If necessary, the vessel can safely
be followed proximally into the parotid tissue to obtain a larger-
caliber vessel (Figure 5). If the vascular pedicle is not long enough
to reach the vessels, then interposition veins would be necessary.
Other options include the facial vessels and the external jugular vein.
However, cosmesis remains a significant problem with free flaps be-
cause of alopecia as well as color and contour mismatch.
The latissimus dorsi flap provides an excellent option for recon-
structing large or total scalp defects.19 Other flap options for me-
dium to large defects include the radial forearm, anterolateral thigh
(ALT), gracilis, lateral arm, parascapular, rectus abdominis, Scarpa
adipofascial flap, and omental flaps.18,64-72 It should be noted that
in cases of latissimus dorsi or rectus muscle flaps, only the muscle
is taken and not the overlying skin, because the subcutaneous fat is
often too bulky and provides poor scalp contour. It is for this rea-
son that skin grafting is performed over the muscle. However, ra-
dial forearm and ALT flaps often have minimal subcutaneous fat in
the skin paddle, which provides adequate scalp contour, thus pre-
cluding the need for a skin graft. After reviewing the literature, it is
apparent that most flaps have a very high success rate, and the choice
of flap depends on the surgeon’s familiarity and comfort level. Nu-
merous studies have also shown their safety and efficacy in the el-
derly population.73-75
Algorithmic Approach to Defect
Several algorithms for scalp reconstruction have been proposed in
the literature based either on location, size, and etiology of the de-
fect, quality of tissue and/or wound environment, structures ex-
posed, and hairline distortion.1,18,34,76,77 Leedy et al1 described 4 sepa-
rate algorithms based on location: anterior, parietal, occipital, or
vertex. The second factor to consider in their decision tree in the first
JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1 63
 Clinical Review & Education Review Scalp Reconstruction

Figure 6. Algorithm for the Reconstruction of Various Scalp Defects

Scalp Small Medium Large Total

defect size: (<9 cm2) (9 to 30 cm2) (>30 cm2) scalp

Frontal, Vertex Frontal, Vertex Frontal, vertex Temporoparietal,

Defect location: temporoparietal, temporoparietal, occipital
occipital occipital

Radiation Radiation No Radiation Radiation Radiation

history: history? history? history? history?

Yes No

Hairline Yes Hairline No Hairline

Hairline:
distortion? distortion? distortion?

Yes No Yes No Yes No No Yes

Ideal Local Primary Primary Free tissue Tissue Local Skin graft Free tissue Tissue Orticochea Tissue Free tissue Free tissue
reconstructiona: flapb closure closure, transfer expansion flapb (bald transfer expansion flap expansion transfer, transfer
“pinwheel” patient), consider
or large regional
0→Z flap rotational flap
flap

Algorithm for the reconstruction of various scalp defects based on size and functional and aesthetic outcome; however, often that reconstructive option
location. See the section Algorithmic Approach to Defect for further details. may not be feasible.
a b
Ideal reconstruction refers to the surgical option that could achieve an optimal Local flaps include advancement, rotation, and transposition flaps.

3 locations is distortion of the hairline. However, they do not ac-
count for history of radiation or quality of the tissue or wound en-
vironment, which is a major factor to consider for the healing of large
reconstructions. Newman et al18 described a simpler method of re-
construction first based on size: small (<10 cm2), medium (10-50
cm2), or large (>50 cm2). The second factor to consider is quality of
local tissue described as “good” or “poor.” However, they did not con-
sider defect location or hairline distortion, which are both signifi-
cant functional and aesthetic concerns. Iblher et al34 described an
algorithm specific to oncologic reconstruction for scalp reconstruc-
tion with the primary considerations being clear surgical margins,
followed by defect size; however, they did not account for location
or quality of tissue. Beasley et al76 created a bimodal algorithm based
on location in the forehead or scalp, followed by size (ⱖ50 cm2), and
they accounted for tissue quality. However, this algorithm is rather
broad and does not consider hairline or specific location in the scalp.
The purpose of this proposed algorithm is to provide a compre-
hensive view on how to approach scalp defects while taking into ac-
count several key factors that have been previously repeatedly de-
scribed in the literature by many experienced reconstructive
surgeons (Figure 6).1,18,34,76,77 The 4 most important factors that have
been described in the literature, and thus have been included in this
novel comprehensive algorithm, include scalp defect size, defect lo-
cation, radiation history, and hairline distortion. Finally, this algo-
rithm refers to the surgical option that could achieve an optimal func-
tional and aesthetic outcome; however, that reconstructive option
may not always be feasible.
Conclusions
Ideal reconstruction of scalp defects relies on a comprehensive un-
derstanding of scalp anatomy, a full consideration of the armamen-
tarium of surgical techniques, and a detailed appraisal of patient fac-
tors and expectations. Scalp defects vary in size, location, local tissue
quality, and hairline distortion, and the reconstructive goal must be
tailored to the individual patient. The facial reconstructive surgeon
is challenged to be thoughtful, creative, and meticulous in order to
provide the patient with an optimal outcome both functionally and
aesthetically.

ARTICLE INFORMATION Drafting of the manuscript: Desai, Sand, Branham, REFERENCES

Accepted for Publication: August 4, 2014.
Published Online: November 6, 2014.
doi:10.1001/jamafacial.2014.889.
Author Contributions: Dr Desai had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Desai, Sand, Sharon,
Nussenbaum.
Acquisition, analysis, or interpretation of data: All
authors.
Nussenbaum.
Critical revision of the manuscript for important
intellectual content: All authors.
Administrative, technical, or material support: Desai,
Sand, Sharon, Nussenbaum.
Study supervision: Desai, Branham, Nussenbaum.
Conflict of Interest Disclosures: None reported.
Additional Contributions: Bruce H. Haughey,
MBChB, Department of Otolaryngology–Head and
Neck Surgery, Washington University School of
Medicine, provided clinical photographs. He was
not compensated for his contribution.
1. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of
acquired scalp defects: an algorithmic approach.
Plast Reconstr Surg. 2005;116(4):54e-72e.
2. Freund RM. Scalp, calvarium and forehead
reconstruction. In: Aston SJ, Beasley RW, Thorne
CHM, eds. Grabb and Smith’s Plastic Surgery.
Philadelphia, PA: Lippincott-Raven; 1997:473.
3. Shestak KC, Ramasastry SS. Reconstruction of
defects of the scalp and skull. In: Cohen M, ed.
Mastery of Plastic and Reconstructive Surgery. Boston,
MA: Little, Brown; 1994:830-841.

64 JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1 jamafacialplasticsurgery.com

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015

 Scalp Reconstruction
4. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ.
The surgical anatomy of the scalp. Plast Reconstr Surg.
1991;87(4):603-612.
5. Moss CJ, Mendelson BC, Taylor GI. Surgical
anatomy of the ligamentous attachments in the
temple and periorbital regions. Plast Reconstr Surg.
2000;105(4):1475-1490.
6. Elliott LF, Jurkiewicz MJ. Scalp and calvarium. In:
Jurkiewicz MJ, Krizek TJ, Mathes SJ, Ariyan S, eds.
Plastic Surgery: Principles and Practice. St Louis, MO:
Mosby; 1990:419-440.
7. Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE.
Clinical applications of the subgaleal fascia. Plast
Reconstr Surg. 1991;87(4):615-626.
8. Ducic Y. Reconstruction of the scalp. Facial Plast
Surg Clin North Am. 2009;17(2):177-187.
9. Hoffmann JF. Reconstruction of the scalp. In:
Baker SR, ed. Local Flaps in Facial Reconstruction.
St Louis, MO: Mosby; 2007:638.
10. Seery GE. Surgical anatomy of the scalp.
Dermatol Surg. 2002;28(7):581-587.
11. Miller GDH, Anstee EJ, Snell JA. Successful
replantation of an avulsed scalp by microvascular
anastomoses. Plast Reconstr Surg. 1976;58(2):133-
136.
12. Kaplan HY, Yaffe B, Borenstein A. Single artery
replantation of totally avulsed scalp. Injury. 1993;24
(7):488-490.
13. Cappello ZJ, Augenstein AC, Potts KL,
McMasters KM, Bumpous JM. Sentinel lymph node
status is the most important prognostic factor in
patients with melanoma of the scalp. Laryngoscope.
2013;123(6):1411-1415.
14. Close LG, Goepfert H, Ballantyne AJ, Jesse RH.
Malignant melanoma of the scalp. Laryngoscope.
1979;89(8):1189-1196.
15. Mosser SW, Guyuron B, Janis JE, Rohrich RJ.
The anatomy of the greater occipital nerve:
implications for the etiology of migraine headaches.
Plast Reconstr Surg. 2004;113(2):693-697.
16. Becker GD, Adams LA, Levin BC. Secondary
intention healing of exposed scalp and forehead
bone after Mohs surgery. Otolaryngol Head Neck Surg.
1999;121(6):751-754.
17. Goessler UR, Bugert P, Kassner S, et al. In vitro
analysis of radiation-induced dermal wounds.
Otolaryngol Head Neck Surg. 2010;142(6):845-850.
18. Newman MI, Hanasono MM, Disa JJ, Cordeiro
PG, Mehrara BJ. Scalp reconstruction: a 15-year
experience. Ann Plast Surg. 2004;52(5):501-506.
19. Hussussian CJ, Reece GP. Microsurgical scalp
reconstruction in the patient with cancer. Plast
Reconstr Surg. 2002;109(6):1828-1834.
20. Sittitavornwong S, Morlandt AB.
Reconstruction of the scalp, calvarium, and frontal
sinus. Oral Maxillofac Surg Clin North Am. 2013;25
(2):105-129.
21. Chang KP, Lai CH, Chang CH, Lin CL, Lai CS, Lin
SD. Free flap options for reconstruction of
complicated scalp and calvarial defects: report of a
series of cases and literature review. Microsurgery.
2010;30(1):13-18.
22. Barrera A. The use of micrografts and
minigrafts for the treatment of burn alopecia. Plast
Reconstr Surg. 1999;103(2):581-584.
jamafacialplasticsurgery.com
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
23. Nordström REA. Punch hair grafting under
split-skin grafts on scalps. Plast Reconstr Surg. 1979;
64(1):9-12.
24. Limmer BL, Buchwach KA. Hair transplantation
using follicular unit micrografting. Facial Plast Surg.
1999;7(4):523-535.
25. Snow SN, Stiff MA, Bullen R, Mohs FE, Chao
WH. Second-intention healing of exposed
facial-scalp bone after Mohs surgery for skin cancer:
review of ninety-one cases. J Am Acad Dermatol.
1994;31(3, pt 1):450-454.
26. Subotic U, Kluwe W, Oesch V.
Community-associated methicillin-resistant
Staphylococcus aureus-infected chronic scalp
wound with exposed dura in a 10-year-old boy:
vacuum-assisted closure is a feasible option: case
report. Neurosurgery. 2011;68(5):1481-1483.
27. Powers AK, Neal MT, Argenta LC, Wilson JA,
DeFranzo AJ, Tatter SB. Vacuum-assisted closure
for complex cranial wounds involving the loss of
dura mater. J Neurosurg. 2013;118(2):302-308.
28. Marathe US, Sniezek JC. Use of the
vacuum-assisted closure device in enhancing
closure of a massive skull defect. Laryngoscope.
2004;114(6):961-964.
29. Brenner M. Scalp reconstruction. In: Branham
G, ed. Facial Soft Tissue Reconstruction. Shelton, CT:
Peoples Medical Publishing House; 2011:120.
30. Fang RC, Galiano RD. A review of becaplermin
gel in the treatment of diabetic neuropathic foot
ulcers. Biologics. 2008;2(1):1-12.
31. Harrison-Balestra C, Eaglstein WH, Falabela AF,
Kirsner RS. Recombinant human platelet-derived
growth factor for refractory nondiabetic ulcers:
a retrospective series. Dermatol Surg. 2002;28(8):
755-759.
32. Hershcovitch MD, Hom DB. Update in wound
healing in facial plastic surgery. Arch Facial Plast Surg.
2012;14(6):387-393.
33. Raposio E, Nordström RE, Santi PL.
Undermining of the scalp: quantitative effects. Plast
Reconstr Surg. 1998;101(5):1218-1222.
34. Ibhler N, Ziegler MC, Penna V, Eisdenhardt SU,
Stark GB, Bannasch H. An algorithm for oncologic
scalp reconstruction. Plast Reconstr Surg. 2010;126
(2):450-459.
35. Cox AJ III, Wang TD, Cook TA. Closure of a scalp
defect. Arch Facial Plast Surg. 1999;1(3):212-215.
36. Worlicek C, Kaufmann R. Divided full-thickness
skin graft for closure of circular and oval scalp
defects. J Dtsch Dermatol Ges. 2012;10(4):274-276.
37. Kuwahara M, Hatoko M, Tanaka A, Yurugi S,
Mashiba K. Simultaneous use of a tissue expander
and skin graft in scalp reconstruction. Ann Plast Surg.
2000;45(2):220.
38. Terranova W. The use of periosteal flaps in
scalp and forehead reconstruction. Ann Plast Surg.
1990;25(6):450-456.
39. Molnar JA, DeFranzo AJ, Marks MW.
Single-stage approach to skin grafting the exposed
skull. Plast Reconstr Surg. 2000;105(1):174-177.
40. Mehrara BJ, Disa JJ, Pusic A. Scalp
reconstruction. J Surg Oncol. 2006;94(6):504-508.
41. Yeong EK, Huang HF, Chen YB, Chen MT. The
use of artificial dermis for reconstruction of full
thickness scalp burn involving the calvaria. Burns.
2006;32(3):375-379.
JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1
Review Clinical Review & Education
42. Tufaro AP, Buck DW II, Fischer AC. The use of
artificial dermis in the reconstruction of oncologic
surgical defects. Plast Reconstr Surg. 2007;120(3):
638-646.
43. Komorowska-Timek E, Gabriel A, Bennett DC,
et al. Artificial dermis as an alternative for coverage
of complex scalp defects following excision of
malignant tumors. Plast Reconstr Surg. 2005;115(4):
1010-1017.
44. Koenen W, Goerdt S, Faulhaber J. Removal of
the outer table of the skull for reconstruction of
full-thickness scalp defects with a dermal
regeneration template. Dermatol Surg. 2008;34(3):
357-363.
45. Gonyon DL Jr, Zenn MR. Simple approach to
the radiated scalp wound using INTEGRA skin
substitute. Ann Plast Surg. 2003;50(3):315-320.
46. Khan MA, Ali SN, Farid M, Pancholi M, Rayatt S,
Yap LH. Use of dermal regeneration template
(Integra) for reconstruction of full-thickness
complex oncologic scalp defects. J Craniofac Surg.
2010;21(3):905-909.
47. Jung SN, Chung JW, Yim YM, Kwon H.
One-stage skin grafting of the exposed skull with
acellular human dermis (AlloDerm). J Craniofac Surg.
2008;19(6):1660-1662.
48. Wilensky JS, Rosenthal AH, Bradford CR, Rees
RS. The use of a bovine collagen construct for
reconstruction of full-thickness scalp defects in the
elderly patient with cutaneous malignancy. Ann
Plast Surg. 2005;54(3):297-301.
49. Seyhan A, Yoleri L, Barutçu A. Immediate hair
transplantation into a newly closed wound to
conceal the final scar on the hair-bearing skin. Plast
Reconstr Surg. 2000;105(5):1866-1870.
50. Frodel JL, Mabrie D. Optimal elective scalp
incision design. Otolaryngol Head Neck Surg. 1999;
121(4):374-377.
51. Orticochea M. Four flap scalp reconstruction
technique. Br J Plast Surg. 1967;20(2):159-171.
52. Orticochea M. New three-flap reconstruction
technique. Br J Plast Surg. 1971;24(2):184-188.
53. Horch RE, Stark GB. The contralateral bilobed
trapezius myocutaneous flap for closure of large
defects of the dorsal neck permitting primary donor
site closure. Head Neck. 2000;22(5):513-519.
54. Uğurlu K, Ozçelik D, Hüthüt I, Yildiz K, Kilinç L,
Baş L. Extended vertical trapezius myocutaneous
flap in head and neck reconstruction as a salvage
procedure. Plast Reconstr Surg. 2004;114(2):339-350.
55. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. The
lower trapezius musculocutaneous flap revisited:
versatile coverage for complicated wounds to the
posterior cervical and occipital regions based on the
deep branch of the transverse cervical artery. Plast
Reconstr Surg. 2002;109(2):444-450.
56. Tanaka Y, Miki K, Tajima S, Akamatsu J,
Tsukazaki Y, Inomoto T. Reconstruction of an
extensive scalp defect using the split latissimus
dorsi flap in combination with the serratus anterior
musculo-osseous flap. Br J Plast Surg. 1998;51(3):
250-254.
57. Har-El G, Bhaya M, Sundaram K. Latissimus
dorsi myocutaneous flap for secondary head and
neck reconstruction. Am J Otolaryngol. 1999;20(5):
287-293.
58. Kim JC, Hadlock T, Varvares MA, Cheney ML.
Hair-bearing temporoparietal fascial flap
65
 Clinical Review & Education Review
reconstruction of upper lip and scalp defects. Arch
Facial Plast Surg. 2001;3(3):170-177.
59. Tellioğlu AT, Tekdemir I, Erdemli EA, Tüccar E,
Ulusoy G. Temporoparietal fascia: an anatomic and
histologic reinvestigation with new potential clinical
applications. Plast Reconstr Surg. 2000;105(1):40-
45.
60. Baker SR, Swanson NA. Tissue expansion of
the head and neck: indications, technique, and
complications. Arch Otolaryngol Head Neck Surg.
1990;116(10):1147-1153.
61. O’Reilly AG, Schmitt WR, Roenigk RK, Moore EJ,
Price DL. Closure of scalp and forehead defects
using external tissue expander. Arch Facial Plast Surg.
2012;14(6):419-422.
62. Chaouat M, Lalanne B, Levan P, Mimoun M.
Skin expansion and external tissue extension
techniques in the treatment of a traumatic scalp
defect. Scand J Plast Reconstr Surg Hand Surg.
2002;36(1):50-52.
63. Yuen JC, Hochberg J. Free flap coverage of
scalp defects following radiation. J Ark Med Soc.
2003;100(6):194-195.
64. Borah GL, Hidalgo DA, Wey PD. Reconstruction
of extensive scalp defects with rectus free flaps.
Ann Plast Surg. 1995;34(3):281-285.
66 JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of California - San Diego User on 06/05/2015
65. Lutz BS. Aesthetic and functional advantages
of the anterolateral thigh flap in reconstruction of
tumor-related scalp defects. Microsurgery. 2002;22
(6):258-264.
66. Ikuta Y. Microvascular free transfer of
omentum. In: Vasconez LO, Strauch B, eds. Grabb’s
Encyclopedia of Flaps. 2nd ed. Philadelphia, PA:
Lippincott-Raven; 1998:42-44.
67. Wax MK, Burkey BB, Bascom D, Rosenthal EL.
The role of free tissue transfer in the reconstruction
of massive neglected skin cancers of the head and
neck. Arch Facial Plast Surg. 2003;5(6):479-482.
68. Lee B, Bickel K, Levin S. Microsurgical
reconstruction of extensive scalp defects.
J Reconstr Microsurg. 1999;15(4):255-262.
69. Lutz BS, Wei FC, Chen HC, Lin CH, Wei CY.
Reconstruction of scalp defects with free flaps in 30
cases. Br J Plast Surg. 1998;51(3):186-190.
70. Pennington DG, Stern HS, Lee KK. Free-flap
reconstruction of large defects of the scalp and
calvarium. Plast Reconstr Surg. 1989;83(4):655-661.
71. Chicarilli ZN, Ariyan S, Cuono CB. Single-stage
repair of complex scalp and cranial defects with the
free radial forearm flap. Plast Reconstr Surg. 1986;
77(4):577-585.
Scalp Reconstruction
72. Koshima I, Inagawa K, Jitsuiki Y, Tsuda K,
Moriguchi T, Watanabe A. Scarpa’s adipofascial flap
for repair of wide scalp defects. Ann Plast Surg.
1996;36(1):88-92.
73. Serletti JM, Higgins JP, Moran S, Orlando GS.
Factors affecting outcome in free-tissue transfer in
the elderly. Plast Reconstr Surg. 2000;106(1):66-70.
74. Shestak KC, Jones NF, Wu W, Johnson JT,
Myers EN. Effect of advanced age and medical
disease on the outcome of microvascular
reconstruction for head and neck defects. Head Neck.
1992;14(1):14-18.
75. Coskunfirat OK, Chen HC, Spanio S, Tang YB.
The safety of microvascular free tissue transfer in
the elderly population. Plast Reconstr Surg. 2005;
115(3):771-775.
76. Beasley NJ, Gilbert RW, Gullane PJ, Brown DH,
Irish JC, Neligan PC. Scalp and forehead
reconstruction using free revascularized tissue
transfer. Arch Facial Plast Surg. 2004;6(1):16-20.
77. Temple CL, Ross DC. Scalp and forehead
reconstruction. Clin Plast Surg. 2005;32(3):377-390,
vi-vii.
jamafacialplasticsurgery.com